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Skin Radiation therapy > Brachytherapy for GYNE > Flashcards

Brachytherapy for GYNE Flashcards

1
Q

What constitutes a high risk of recurrence for cervical cancer?
what does this indicate treatment wise?

A

high risk of recurrence in cervical cancer:
-close or involved surgical margins
-Lymphovascular invasion
-more than one +LN
This means post op EBRT to the pelvis followed by brachytherapy intravaginally will be given

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2
Q

what constitutes a high risk of recurrence for the endometrium?
what does this indicate treatment wise?

A

High risk of recurrence with endometrial cancer:
-High grade >G3
-stage 1B (invasion of outer half of myometrium)
-Stage 2
in these patients post op EBRT to the pelvis followed by brachytherapy intravaginally will be given

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3
Q

which brachytherapy are offered for gyne? and which is preferred? why?

A

all types: LDR, PDR and HDR are offered, but aHDR is preferred because it eliminates the need for eh patient to be hospitalized

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4
Q

vaginal applicator options (3) for post hysterectomy

A

1.vaginal cylinders of varying circumference are available
2 ovoid rings
3.Vaginal moulds

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5
Q

what is the amount/ distance treated when using ovoid/rings and what is the distance treated when using cylinders ?

A

for ovoids, the dose is only treated to the upper 1-2 cm of the vagina
for the cylinder 5cm of the vagina is treated

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6
Q

best applicator for cervical cancer, endometrial cancer?

A

vaginal cylinder is thought to be best for endometrial cancer because the main risk of spread is to the submucosal lymphatic infiltration. in cervical cancer post hysterectomy where the vaginal margin is close, the ovoids would be abetter option

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7
Q

preparation for brachytherapy procedure

A

constipation (for LDR and PDR using codeine 6mg) and full bladder for all types to displace the small bowel , patient will also be catheterized during the treatment

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8
Q

doses for LDR/PDR and HDR what is the EBRT dose preceding it?

A

EBRT is delivered at 40-45Gy/25fx and then…
LDR/PDR is delivered at 15Gy at 5mm at .5Gy/Hr therefore 30hours total
the EBRT will be 50Gy in 25-28Fx
HDR will deliver 11Gy in 2 fractions

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9
Q

side effects from brachytherapy

A

acute- cystitis - this is more often from the catheterization though
proctitis and looser stools
late- sexual dysfunction, vaginal stenosis- aided by vaginal dilators and vaginal telangiecastia

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10
Q

doses for brachy alone post hysterectomy for LDR PDR and HDR

A

40-50Gy at 5mm depth at .5Gy/ hour for LDR PDR

HDR: 22Gy /4fx or 21Gy/3fx at 5mm depth

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11
Q

vaginal applicators for brachy alone no hysterectomy forcervical cancer

A
  1. central tube and lateral vaginal sources are called ovoids because of their shape ex: fletcher tube and ovoids and Manchester tube and ovoids
    2.central tube and ring applicator mostly used for HDR
    after loading
    3.singl line source cons is that it increases the dose to the bladder and rectum, most commonly used for stage 2a and 3 a disease
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12
Q

bratty application process for cervical cancer no hysterectomy

A
  1. anesthetic given pt is in lithotomy position
  2. catheter is used and patient is examined for extent of disease
  3. use speculum and grasp cervix with surface, pass uterine sound and measure length
  4. dialate the cavity depending on the size of the applicator to be inserted (typically 7-8 for HDR but larger for LDR)
  5. replace largest dilator with uterine tube
  6. place, align and fix the vaginal and uterine applicators in place
  7. pack vagina, place rectal barium if needed for x-rys
  8. support the applicator with a corset (LDR/PDR)or t bandages (HDR)
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13
Q

pycolpos and brachytherapy

A

pycolpos is a dilation of the vagina due to excessive pus due to genital; tract obstruction .
Brachytherapy via LDR or PDR can not be performed when the patient has this therefore patient needs to go on antibiotics before LDR/PDR can be performed
HDR can be performed however

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14
Q

perforation and brachytherapy

A

usually occurs through the posterior wall of the cervix through the pouch of douglas if perforation occurs during the procedure the procedure is abandoned and tried again in 1 week and the patient should be monitored for the first 24 hours to ensure no infection occurs

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15
Q

point A nd B

A

point A is 2 cm lateral to the m/l and 2 cm above the ovoid in the lateral vaginal fornix
point B is 3cm lateral to point A

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16
Q

3 distinct CTVs

A

high risk CTV(HRCTV)- includes the area of macroscopic residual disease, the GTV and the entire cervix
intermediate CTV(IRCTV)-includes HRCTV +5-15mm
low risk CTV (LRCTV) - includes all potential areas for microscopic disease at the time of Dx

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17
Q

dose is prescribed to ….?

A

point a and to the HRCTV

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18
Q

dose constraints for bladder, sigmoid colon, small bowel and rectum in brachy

A

bladder 90-95gy
sigmoid colon 70-75Gy
small bowel 66Gy
rectum 70-75Gy

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19
Q

dose, alpha beta ratio to be aimed for for non bulky disease for cervical treatment

A

non bulky should have alpha beta ratio of 10 and the dose should be 80Gy to the HRCTV

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20
Q

Dose, alpha beta ratio to be aimed for for bulky disease for cervical treatment

A

bulky should have an alpha beta ratio of 3.5 and 85-90Gy should be given to HRCTV

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21
Q

common prescription dose for bratty to the cervix

A

45/25EBRT then 28/4 HDR bratty
45/25 EBRT then 30/3 at 1Gy/HR PDR
50/25 EBRT then 24/4 HDR bratty
50.4/28 EBRT then 28/4 bratty

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22
Q

how long does a typical HDR cervical bratty treatment take

A

typically 8-10 minutes

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23
Q

which complications from brachytherapy occur first?

A

rectal complications occur before bladder complications

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24
Q

when is brachytherapy preferable to hysterectomy in endometrial cancer?

A

hysterectomy is used when the tumour is confined to the uterus except in the case of patients who can not get a hysterectomy due to obesity or diabetes and hypertension or in patients who’s tumour is past the uterus the patient will receive EBRT+ brachytherapy

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25
Q

what type of applicators are used for endometrial bratty (3)

A
  1. Heymens capsules are a bunch of tiny caesium pellets packed into the uterine cavity that have a high activity
  2. Modern after loading systems that are equival1ent to the the heymens capsules
  3. Rotte Y applicator has 2 intrauterine line sources forming a Y in the cavity
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26
Q

which applicator is used for bulky/ non bulky disease in endometrial cancer

A

single line source is used for smaller tumours and Rotte’s Y and Heymens capsules are typically used for more bulky disease

27
Q

how many Heymens capsules typically fit in the uterus

A

9-12

28
Q

when is the upper vagina included in the CTV of the endometrium brachytherapy

A

if mid or high risk features are identified ( >50% invasion into the wall or G3 histology or stage 2 disease

29
Q

what is typically included in the CTV of endometrial bratty

A

typically the cervical os to the funds will be included in the CTV

30
Q

Dose of brachytherapy alone for medically unfit patients with endometrial stage 1

A

LDR/PDR- 75-80Gy to point A

HDR- 36-42Gy/ 6 fx to point A or the CTV

31
Q

indications for vaginal brachy

A

alone or with EBRT for stage1
as a boost after EBRT for stage 2 and 3
palliative for stage 4 and recurrent tumours

32
Q

indications for vulva brachy

A

primary treatment for small stage 1 tumours
boost after EBRT for locally advanced tumours
palliative treatment for locally advanced or recurrent tumours

33
Q

when is intracavitiary bratty used for vaginal cancer

A

used for superficial tumours doses can be prescribed up to 1cm from the surface PTV must be less than 1cm from the surface

34
Q

intraluminal bratty use in vaginal cancer

A

is used in the palliative setting

35
Q

tumour localization for vaginal cancer

A

CT, MRI US or clinical examination

36
Q

what type of brachy is typically used for vaginal cancer

A

perineal implant

37
Q

typical bratty implant procedure for vaginal brachy

A
  1. preop preparation bowel prep and enema followed by constipation meds
  2. place ptr in lithotomy position pt should receive spinal or general anesthetic
  3. insert urethral catheter and empty bladder. RO will examine the pt under anesthetic to define implant placement and PTV
  4. Align the perineal template
  5. pass needles through template position ensuring they are parallel using US fluoroscopy
  6. build up implant using parallel planes to cover PTV
  7. fix template to skin and secure needles within template
  8. ensure post op analgesia
38
Q

complications to vaginal brachy

A

proctitis, bladde neck and urethral strictures, risk of fistula, vaginal stenosis (10%), recto vagina and vesicle-vaginal fistula in 10% of patients with stage 3-4

39
Q

LDR or PDR vaginal bratty dose

A

sole tx: 60Gy at .5Gy/ hr

after EBRT or CX: 20-25Gy at.5 Gy/hr

40
Q

HDR bratty for vaginal cancer dose

A

sole: 30-3Gy /5-6fx

as a boost after EBRT: 16.5Gy/ 3fx

41
Q

palliative LDR/PDR and HDR doses for vaginal brachy

A

LDR 20-30Gy and HDR of 10Gy/1 or 18024Gy/3-4 Fx

42
Q

there is a 20-50yo spanish gyne pt what is her primary?

A

cervical

43
Q

lymphatics of the cervix

A

PPE,PS

Paraimetrical-pelvic- common iliacs- paraortic-supraclavicular

44
Q

there is a 35 y.o., black woman who presents with back pain, hematuria and pain on intercourse…What is her likely primary?

A

later stage cervical cancer as early stage is typically asymptomatic

45
Q

i am the most deadly gynaecological cancer.. what am I?

A

ovarian cancer

46
Q

at what dose is sterility in women?

What area needs to be radiated for sterility

A

when he ovary is radiated to 8 Gy permanent sterility is seen in women of all ages

47
Q

what is the most common GYNE cancer in women

A

endometrium

48
Q

A 63 y.o. white female has a BMI of 35 and type 2 diabetes, she is diagnosed with a gynaecological cancer, what cancer did she get diagnosed with/?

A

Endometrium

49
Q

a 67 y.o. woman with Lynch Syndrome presents to the XRT department with gone bleeding, what primary cancer does she have ?

A

-post menopausal bleeding, also the pt having Lynch syndrome is most commonly associated with endometrial cancer- the answer to this
Lynch syndrome is also associated with ovarian cancer

50
Q

what 2 gynaecological cancers is lynch syndrome associated with? what other non gone cancer is it associated with?

A

its associated most commonly with endometrial cancer 40-70% and less so with ovarian cancer 12 %
Lynch syndrome is aka hEREDITARY NON POLYPOSIS COLORECTAL CANCER- therefore it is ALSO associated with colorectal cancer

51
Q

Ca-125 tumour marker should be checked in what cancer?

A

high risk endometrial (papillae serous) nd ovarian

52
Q

a 64Y.O jewish woman coms to the clinic with a distended abdomen what gyne cancer is she diagnosed with

A

ovarian

53
Q

what cancer is most common in black women?

A

cervical

54
Q

what cancer is most common in jewish women? why?

A

ovarian, it is associated with BRCA1/2 and jewish women have a higher incidence of ovarian cancer

55
Q

what cancer is associated with BRCA aside from breast cancer?

A

ovarian

56
Q

67 y.o. white woman who has a 29 year old daughter and a 27 year old son, she presents at the radiation department with nausea, and abdominal pain… what is the patients likely primary?

A

ovarian cancer

57
Q

what is the least common gyne cancer

A

vaginal cancer 2% of all cancers

58
Q

A 18 y.o. patient comes to the radiation department with vaginal bleeding and discharge what is her primary?

A

vaginal cancer- clear cell carcinoma- associated with maternal diethylstilbestrol use (1940s-1970s)

59
Q

A 72 yo woman comes to the radiation department, she previously was radiated for CIN, and had a painless mass, what is her primary?

A

vaginal- SCC

60
Q

diarrhea is a possible side effect of XRT what medications may be given to alleviate this?

A

ImmodiumOTC

Lomotil- prescription

61
Q

what type of contrast is used for before CT to delineate the rectum

A

-oral contrast

Barium sulfate

62
Q

Inguinal LN are most commonly tx in which gyne cancer?

A

vaginal or vulvar

63
Q

what gyne structure is most radio tolerant?

A

uterus

64
Q

is brachytherapy for gyne done by manual or remote after loading

A

remote

Skin Radiation therapy (40 decks)

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